Ask the pharmacist...

I was at a conference and someone said his daughter had ended up in hospital because she had stopped smoking when taking clozapine. He said people should seek medical advice if they wanted to stop smoking and were taking clozapine. Is this true – should my son talk to his doctor before trying to stop smoking? Why might he get ill?

Yes, it is true. Anybody on clozapine who smokes and is intending to stop should speak to their prescriber. Smoking has the effect of accelerating the metabolism of clozapine. When smoking is stopped, metabolism slows and the level of clozapine in the blood can double.  Generally speaking, people who successfully stop smoking should have their clozapine dose reduced by up to a half. The exact dose can be estimated by performing plasma level determinations after smoking has stopped. The target clozapine plasma level is around 350 to 500mcg/L. At this level the drug is effective and side-effects are minimised.

I would like to know what the long-term effects of taking psychiatric drugs are: dosulepin (175mg per night) and lamotrigine (50mg per night) for over ten years.

Neither of these medicines is known to have long-term effects. It is possible that drugs like dosulepin (tricyclic antidepressants) can increase the risk of cardiovascular disease and perhaps even the risk of cardiovascular events such as heart attacks.  This is not certain because depression itself increases the risk of cardiovascular disease and so it is difficult to separate the effect of the illness from the drugs used to treat it.  Staying well on dosulepin is probably, for most people, the best course of action since risking relapse by stopping the drug is more dangerous than continuing on it.  It should also be noted that NICE (National Institute for Health and Clinical Excellence) recommends that people are no longer started on dosulepin, but does not recommend that people on it should stop taking it.

My brother age 32 experienced a psychotic crisis two weeks ago. His diagnosis was acute psychotic disorder. Doctors here in Kosovo are giving diazepam and haloperidol combination, two tablets three times a day. Is this adequate therapy?

Tablets contain different amounts of medicine. Haloperidol can be 0.5mg, 1.5mg, 5mg and 10mg. Diazepam can be 2mg, 5mg and 10mg. The optimal dose of haloperidol for most people is between 2mg and 6mg a day. For diazepam, it is usually around 10mg a day.

Sulpiride is said to cause some problems in males such as swollen glands and milk production. Can this be corrected? How? Does sulpiride affect other aspects of sexuality?

Sulpiride can cause breast growth (gynaecomastia) and milk production (galactorrhoea) in both men and women. It may also reduce sexual drive (libido). The usual treatment is to switch to a different antipsychotic that is not associated with these effects. Quetiapine and aripiprazole are drugs which might be used in this respect.

I would like to have a baby... is it okay if my partner continues to take his antipsychotic medication while we are trying?

The short answer is yes. There is no firm evidence that antipsychotics, when taken by the male partner, cause any problems in relation to the developing foetus. Some antipsychotics may reduce male fertility and have sexual adverse effects, particularly those drugs which raise prolactin. It would be worth discussing this with your partner’s psychiatrist.

Someone has recommended my daughter takes a homeopathic remedy to calm her down. Can she take homeopathic medicine at the same time as antipsychotic medication?

Homeopathic remedies essentially contain only water and there is a very low chance of there being any other compounds contained in them. Homeopathic remedies can be safely taken with any other medicines.

My son has schizophrenia and is taking clozapine. He has a blood check every month but nobody has told us why. What are they looking for in his blood?

In about 1 in 100 people, clozapine causes agranulocytosis – a huge reduction in the number of white blood cells. This  means that the body cannot fight infection.  This usually occurs within the first 18 weeks of starting clozapine but is extremely rare after this time. The blood tests are used to try to spot when agranulocytosis is developing so that clozapine can be stopped before the patient comes to any harm.